Basic Information
| Provider Information | |||||||||
| NPI: | 1093187031 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEFFERSON | ||||||||
| FirstName: | JO | ||||||||
| MiddleName: | ETTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3013 N RANCHO DR | ||||||||
| Address2: | SUITE 127 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891303345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026394400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3013 N RANCHO DR | ||||||||
| Address2: | SUITE 127 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891303345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026394400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2015 | ||||||||
| LastUpdateDate: | 10/29/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.